Please read the notes on page 2 for information on when to complete this form.

| Member’s name | Taxpayer’s reference | |---------------|----------------------| | | |

| Member’s address | Employer PAYE reference | |------------------|-------------------------| | | |

| Postcode | National Insurance number | |----------|---------------------------| | | |

Enter the member’s proportionate share of income and gains (as either a fraction or percentage) from the club’s investments

| Date membership started | DD MM YYYY | |-------------------------|------------| | | |

| Investment club’s income for the year ended | 05 04 | |---------------------------------------------|-------| | Club income | | | Tax credits £ | | | Dividends received or net income £ | | | Member’s share | | | Tax credits £ | | | Dividends received or net income £ | |

| UK dividends | Overseas dividends | Savings income taxed at basic rate | Untaxed income | Total income to be shared | |--------------|--------------------|-----------------------------------|----------------|--------------------------| | | | | | |

| Declaration | |-------------| | Please use capital letters |

| First name | Investment club name | |------------|----------------------| | | |

| Surname | Position held for example, Treasurer | |---------|--------------------------------------| | | |

I declare that the information given by me in this certificate is correct and complete to the best of my knowledge and belief.

| Signature | Date DD MM YYYY | |-----------|-----------------| | | |

| Private address | Postcode | |-----------------|----------| | | |

## Schedule of gains and losses made during the year

Include realised gains and losses only

| Date of sale DD MM YYYY | Date of acquisition DD MM YYYY | Name of company and description of holding for example, ordinary or preference share | Club details | Member's share | |-------------------------|---------------------------------|-------------------------------------------------------------------------------------|--------------|----------------| | | | | Net sale proceeds £ | Capital gains £ | Capital losses £ | Net sale proceeds £ | Capital gains £ | Capital losses £ | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

### Notes

Shortly after 5 April the Treasurer or other officer of the club should:

- prepare two copies of this form for each member of the club to indicate the member's share of the income, and capital gains or losses of the club for the year to 5 April
- give one copy to the member, and
- keep the second copy in the club's record.

The member should enter the details from this form onto their own tax return, if one is received. If a member does not normally receive a tax return and they have income or capital gains to declare, they can find guidance if they go to [hmrc.gov.uk](http://hmrc.gov.uk)

For more information about investment clubs go to [hmrc.gov.uk](http://hmrc.gov.uk)